Overview

This is a treatment guideline for a second or greater allogeneic hematopoietic stem cell transplant (HSCT) using a reduced intensity conditioning (RIC) in patients with non-malignant or malignant diseases. This regimen, consisting of busulfan, fludarabine, and low dose total body irradiation (TBI), is designed to promote engraftment in patients who failed to achieve an acceptable level of donor-derived engraftment following a previous allogeneic HCT.

Eligibility

Inclusion Criteria:

• Diagnosis of any disease for which a second or greater hematopoietic stem cell transplant is needed due to insufficient donor chimerism following hematopoietic recovery after previous HSCT. Determination of "insufficiency of donor chimerism" will be made by the treating transplant physician. Occasionally donor derived engraftment may be present, but sustained aplasia or failed recovery of sufficient hematopoiesis requires administration of a second graft. This intervention may be used for both situations.
• Donor Availability: Patients considered for transplantation must have a sufficient graft as based on current criteria of the University of Minnesota Blood and Marrow Transplantation Program
  • Transplantation using sufficiently matched related donors (such as matched siblings) or unrelated donors will be considered. Both granulocyte-colony stimulating factor (GCSF) stimulated peripheral blood grafts and bone marrow grafts will be considered, although bone marrow will be the priority.
  • Cord blood grafts, both related and unrelated, are also eligible. As this protocol will use a reduced intensity regimen, this protocol will use the current recommendations of the University of Minnesota for choosing cord blood grafts. If a single cord blood unit cell dose is insufficient, double cord transplantation should be considered if sufficiently matched cord blood units are available. The priority of choosing cord blood donors is based on the current institutional recommendations.
  • Exclusion of Metabolic Disorder or other Inherited Disorder Carrier Status from related donor and unrelated cord blood grafts as appropriate for primary disease.

        At the discretion of the treating transplant physician, an allograft from the previous
        donor may be used, if available.
          -  Age, Performance Status, Consent
               -  Age: 0 to 55 years
               -  Consent: voluntary written consent (adult or parental/guardian)
        Exclusion Criteria:
          -  Previous irradiation that precludes the safe administration of an additional dose of
             200 cGy of total body irradiation (TBI). Radiation Oncology will evaluate all patients
             who have had previous radiation therapy or TBI for approval to receive an additional
             200 cGy of TBI
          -  Pregnant or breastfeeding
          -  Active, uncontrolled infection - infection that is stable or improving after 1 week of
             appropriate therapy (4 weeks for presumed or documented fungal infections) will be
             permitted
          -  HIV positive
          -  While it would be advantageous to begin therapy on this second transplant regimen > 6
             months following a prior myeloablative regimen or >2 months after a reduced intensity
             regimen, it is recognized that there are circumstances where this may not be
             practical.